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Lean Times and Sacred Cows: Affordable health in times of change.

2nd August 2007

08082007_shambo34.jpgHealth economics are, more often than not, reported in terms of their measured activity returns; the investment in, being reflected in the numbers through.Whereas a true economic review would provide a measure greater than the sum of its parts, the output measure would then be seen in its broader context.

The overall health-spend budget is sometimes publicly understood as the direct spend on the NHS. For many, the NHS equates with the acute sector, and within this, the hospital dimension of overall provision.

Within the plural market that now exists, the previously centrally held command and control structure has been slow to adapt to the required local Gramscian economic delivery of the mixed economy. That is, Payment By Results, Independent Treatment Centres, and the use of service provider contractors. This move, theoretically, provides the opportunity to develop flexible, responsive healthcare to a profile mapped population, potentially enabling the development and effective use of predictive modelling to cope with a forecast demand. Just as old style centralized economics could, on occasion, produce an excess of left-footed shoes, the previous health economic model also produced a surplus, sustained the surplus and continued to stockpile the surplus, of illness.

This can be mirrored against our continued investment in illness, and meagre recognition of the wellness aspect of the overall population, of which prevention and rehabilitation are an example. One argument is that the only way to manage the continued exponential demand and growth for healthcare – which in reality means illness care – is to apply lean thinking to how service provision is discussed, decided and delivered.

Plans for reconfiguration of services, the need to centralize expertise and diversify with polyclinics to provide care in local community settings, appear to be little understood, not least by those they are purported to serve. A restructuring of services is sometimes seen as less of what was there before, accident and emergency midwifery centres, provision, being useful examples of the case in point. The seen media coverage provides ample examples of members of the public and hospital staff protesting to “save? their department against “managers and bureaucrats? and to defend against perceived cuts.

A parallel may be seen with recent footage of the defence and protest surrounding “Shambo? the sacred bull, previously ensconced in a shrine in Wales. Venerated and respected and held in symbolic value as a spiritual reflection of our own humanity, Shambo stood for all that was good. Shambo, it appeared, had plenty of what Bourdieau might refer to as “cultural capital? and thus generated plenty of public support. However, once deemed unfit as the bearer of bovine TB, and following various appeals, protests and a final judgement, a decision was reached that the risk of spread of the disease outweighed the possibility of and sensibilities around Shambo’s continued residence. Following undignified visits by Welsh Assembly officials and latterly the police, which cast all officialdom and their subsequent decision as bad, Shambo was taken away. Again, a case of four legs good, two legs bad, three district general accident and emergency departments better to one centralized service.

In the real world, the ideal and the less than perfect co-habit to construct our experience, often in reaction to the either or by dint of having to make a choice. It’s either this or that. In both cases, the reality of the two sides lies somewhere in between either extreme. The truth is that there is a myriad discussion and consideration that is context-specific and that informs the continued planning for health services. For Shambo, or the local maternity unit, the lean cut may be the unkindest of all; however, the need and provision of and for the greater good must prevail. Sacred cows may no longer be affordable in either context.

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